The Impact of Vitamin D Deficiency During Pregnancy: A Biology Report

This biology assignment report investigates the significant impact of Vitamin D deficiency during pregnancy on both the mother and the developing fetus. It highlights the adverse effects, including impaired fetal growth, bone development issues, and increased risks of conditions like rickets, hypocalcaemia, preeclampsia, and gestational diabetes. The report reviews existing literature and research studies, including randomized controlled trials (RCTs), conducted to assess the effectiveness of Vitamin D supplementation, particularly in high-risk populations such as Indian and Asian women. The study objectives focus on understanding the consequences of Vitamin D deficiency and evaluating the efficacy and safety of different supplementation dosages (2000 IU and 4000 IU) compared to the standard recommended dose of 400 IU/d. The methodology involves a controlled, double-blind, and randomized study design with pregnant Indian women, assessing various outcomes such as Vitamin D metabolites, PTH levels, and calcium levels. The report emphasizes the need for adequate Vitamin D levels during pregnancy and discusses the importance of supplementation to achieve optimal health outcomes for both mothers and their infants.

Running head: BIOLOGY ASSIGNMENT
HEADING
Name of the Student:
Name of the University:
Authors note

1BIOLOGY ASSIGNMENT
In the recent studies it has been observed that several conditions are responsible for
decreasing the Vitamin D concentration in mother that tends to cause severe effects in
mothers as well as in the fetus (Anatoliotaki et al. 2003). The low Vitamin D content during
pregnancy of a woman has been related with obstructed growth of the fetus and also show
severe impairment in the bone formation. The mothers with inadequate Vitamin D in their
body has shown to give birth to children with hypocalcaemia as well as rickets, and it has
been also observed in the masses where there is already Vitamin D deficiency (Hyppönen et
al. 2013). The elevated risk associated with skin diseases and lower respiratory tract infection
is associated with low cord serum 25-hydroxyvitamin D [25(OH) D], which mainly occurs
during first year of the child (Ioannou et al. 2012). Apart from these it has been observed
that with inadequate Vitamin D in mothers may also lead to the higher risk factors for
bacterial vaginitis, increase elevation of blood pressure, high protein urine (which can lead to
preeclampsia) and also gestational diabetes in pregnant mothers (Dawodu et al., 2013).
It has been observed that there is usual decrease of Vitamin D commonly happens
during pregnancy especially in Asian specifically in Indian women, which is less than
20ng/mL or < 50 nmol/L in the body fluid (Ioannou et al. 2012).
Numerous researches has been conducted in various part of the world in this
particular subject which shows that there is 74% vitamin D deficiency in women of
downtrodden mass during pregnancy, 98% Vitamin D deficiency of pregnant women in UAE
and 83% deficiency in Vitamin D in Kuwaiti pregnant women (Dawodu et al., 2013).
Further, it has also been reported that there is lack of supplements of this particular vitamin
and there is also less randomized control or RCTs trials in the population with high risk of
Vitamin D deficiency. The adequate amount of sufficient Vitamin D in the body has been
observed as more than 2000 IU/d which is optimum with 25(OH) D 32 ng/mL or may be
1

2BIOLOGY ASSIGNMENT
greater than or equal to 80 nmol/L which is found in men as well as non pregnant women of
North America (Anatoliotaki et al. 2003).
Supplementing 100 IU of Vitamin D could increase the serum level of 25(OH) D by
0.4–0.8 ng/mL (1–2 nmol/L) which is a pharmacokinetic measure observed in adults.
Depending on such data as well as the high occurrence of vitamin D deficiency in the UAE
population, it is estimated that 4000 IU/d vitamin D3 supplementation would reach vitamin D
sufficiency. On the basis of this pharmacokinetic data, the increased rate of deficiency of
Vitamin D in endemic population can be overcome by supplementation of 4000 IU/d of
Vitamin D3.
This research has been an addition to the present ongoing protocol of National
Institutes of Health-funded study (NCT02292591), regarding the supplementation of 2000 as
well as 4000 I/d of Vitamin D3 among pregnant women in the country. A random control trial
was conducted by us, with the supplementation of Vitamin D on pregnant Indian women and
their children in UAE (Ioannou et al. 2012).
In the research conducted by us, the tested hypothesis confirmed that the required
vitamin D dose supplementation in order to improve the Vitamin D deficiency status in
pregnant women could be doses of 2000 or 4000 IU/d, and not 400 IU/d which a usual
standard recommended dose. It was also observed that 4000 IU is much superior in efficacy
that 2000 IU to gain the optimum and sufficient required Vitamin D for the mother’s infant
during birth without exceeding the toxic level of Vitamin D in the body. From the reports
from the literature review the priori cut off point of blood serum level 25(OH)D or 32 ng/mL
was found to be greater in case of Vitamin D sufficiency (Ioannou et al. 2012).
2

3BIOLOGY ASSIGNMENT
2. THE STUDY OBJECTIVES
 The key objective and purpose of the research is to study VITAMIN D
SUPPLEMENTATION & CONSEQUENCES OF VITAMIN D DEFICIENCY IN
PREGNANT WOMEN.
 The study also aimed to understand the effectiveness and clinical
safety of 4000 IU and 2000 IU in the prenatal cases with respect to the standard
suggested dose of 400IU/d Vitamin D3.
3. LITERATURE REVIEW
The replacement of Vitamin D and the effect of deficiency of Vitamin D
among pregnant women during and the effect of deficiency of Vitamin D on fetus has
not been defined yet and remains questionable.
In a recent study by Hyppönen et al. (2013) it was proposed that vitamin D
has a vital role in skeletal development and its homeostasis of the infants during the
gestation period of the mother. It was also reported in the research publication which
was regarding craniobates that deficiency of Vitamin D can cause neo natal seizures
and newborns with hypocalcaemia.
During the gestation period the functioning of Vitamin D is very sensitive, and
the deficiency of the Vitamin D may lead to adverse effects on various systems of the
body which includes immune system, musculoskeletal, neural as well as
cardiovascular function of the newborn. Current studies determine the role of Vitamin
D and pregnancy consequences such as preeclampsia and cesarean section. The report
further states that vitamin D plays a significant role during pregnancy which includes:
preeclampsia and cesarean section (Dawodu et al., 2013).
3

4BIOLOGY ASSIGNMENT
In a review paper published by Ioannou et al. (2012), it was published there
is lack of data when it comes to vitamin D supplement and its effect during
pregnancy. In this review it had listed 7 records in relation to the topic, within which 4
studies reported the clinical results, but it was not sufficient for the evaluation of the
effects of Vitamin D and its supplementation during the gestation period.
In the year Sørensen et al. (2012) started the 6 year randomized double-blind
and placebo-control trial of Vitamin D supplementation on pregnant women to
understand the clinical safety outcomes which was approved by Investigational Drug
Application with respect to FDA (#66,346). In our hypothesis it was observed that
4000 IU per day vitamin D3 was more effective than 2000 IU per day and the standard
dose of 400 UI per day which had gained circulating 25 (OH) D level of 80nmoL/L or
32ng/Ml in pregnant women irrespective of the race throughout the gestation period
as well as during delivery without raising clinical safety concern.
On the basis of the research observed over the years it was found minimal
value was 80 nmol/L with respect to 25(OH)D levels which had suppressed secondary
hyperthyroidism, the bone density and absorption of calcium in the intestine.
4. METHODOLOGY
Trial design and participants
The following trial was maintained as controlled, double-blind and
randomized study of the supplementation of Vitamin D with 400, 200 and 400 IU was
given to the pregnant Indian women. All the studies were processed in primary
healthcare units and the participants were pregnant expectant Indian mothers who
were at clinics and later on shifted to Max hospital for delivery. Eligible patients who
consented were enrolled in the study. The subject’s eligibility criteria were based on
4

5BIOLOGY ASSIGNMENT
the following basis: i) the expectant mothers were to receive delivery and prenatal
care at Al Shaheen Paramedical College & Hospital, mashrakii) the mothers who
were expecting singleton pregnancy iii) the mothers were at gestation period of 12th to
16th week, since their last menstrual cycle or period and by ultrasonography. There
was an exclusion criterion as well: the mothers who had pre-existing calcium as well
as parathyroid conditions, type 1 diabetes, liver, thyroid disease and kidney disease
which had probable effect to the calcium or the Vitamin D levels were excluded.
Initial visit
A questionnaire was included that mentioned the social, demographic,
pregnancy and status which were to be informed. To calculate the calcium intake and
vitamin D the mothers had to complete a standardized food frequency questionnaire
that was followed in Middle Eastern culture. The pregnant mother’s height and weight
were documented, to understand the body mass index of the woman (BMI) [weight in
kilograms /height in square meters). The maternal blood sample was collected by
puncture and the urinary samples were also collected.
Interventions
Vitamin D supplementation
The Vitamin D supplementation were done by giving Vitamin D tablets of
1600 IU and 3600 Vitamin D3, there was also placebo drug which was similar in taste
and color were manufactured. The subjects were given a supply of vitamin D3 tablets
and that was followed by 1 of the 3 dosage as treatment which was determined by the
process of randomization. There was supply of prenatal vitamins which had 400 IU
vitamin D3 in one tablet, was followed for 90 days.
5

6BIOLOGY ASSIGNMENT
Hence, every subject had received the standard recommended dose of 400 IU
vitamin D3, 2000 UI which is considered has higher safer consumption and 4000 IU
vitamin D3. It was done to achieve the average mean of 25(OH) D concentration of ≥
32 ng/mL, as it is considered to be the optimum Vitamin D level in the body.
Randomization
The randomization of the study was classified in to a block design, such that
every month there was an estimated equal number of participants who were assigned
randomly given 400 IU/d, 2000 IU/d and 400 IU/d, to get a balanced population for
the research in the season.
There were nurses in the research study who were guided by the two
investigator (G.B. and H.F.S). The volunteers and the nurses were provided with
vitamin D and prenatal Vitamin D supplements. The health care workers, the
volunteers, project workers were subjected to the blinded treatment.
Follow-up visits
A monthly inspection was held by a nurse from the date of enrollment till the
delivery. Each participant was subjected to monthly visit which consisted of routine
prenatal checkups. The appointed nurses were to complete a questionnaire regularly,
to record the maternal health and to document all the medical history in relation with
the hospital admission and diagnosis. The documented medical report consisted of the
following: the type of delivery, any complications faced during the delivery, the
weight of the new born (in grams), crown-heel length (in centimeters) and the head
circumference (in centimeters).
Medication compliance
6

7BIOLOGY ASSIGNMENT
To recognize the medication compliance, number of drugs consumed by
mother was divide by the standard range of medication required. Further, it was
calculated and documentation of medical adherence of the patient was performed
during the visit to the facility. Prior to the visit the patients and awareness regarding
their upcoming check-ups and appointments were spread among them. However, if in
any circumstances, patients failed to show up to the facility, their schedule was
rearranged and hence, doctor visit was assured.
Outcome variables
Vitamin D metabolites and PTH
Serum 25(OH)D and intact PTH were assessed at enrollment and 16, 28, and
40 weeks or the time of delivery and in the cord blood at Al Shaheen Paramedical
College & Hospital, Mashrak.
During 16th, 28th and 40th week of fetus development period and at the time of
delivery umbilical cord blood levels and associated content of parathyroid hormone
and blood serum levels 25(OH)D were recorded at Cincinnati Children’s hospital. The
blood Serum 25(OH)D was recorded by RIA (DiaSorin, Stillwater, Minnesota). The
priori cut off was set as 25(OH)D 32 ng/mL and more than that was used as a marker
for cholecalciferol sufficiency measure. The PTH concentrations were assessed by
immune radiometric assay (DiaSorin). The para thyroid hormone levels in the blood
was measured by immune radiometric assay (DiaSorin). It was noted that the normal
level of assay may vary between 13- 54 pg/ml.
Serum calcium, urine calcium and creatinine
The assessment regarding the blood calcium levels as well as the maternal
7

8BIOLOGY ASSIGNMENT
blood levels were measured at Max Hospital to comprehend the calcium homeostasis
and clinical safety. Besides these, the level of urine calcium and creatinine
concentration were determined to understand the the monthly visit to calculate the
urine calcium (Ca) and Creatinine (Cr) ratio. It served as the measures in any case of
hypevitaminosis D.
Safety assessment
Based on the Investigational New Drug (IND) process and protocol, it was
found that the upper limit of the serum was 25(OH) D which is 90 ng/mL or more
than (≥225 nmol/L). Successively the Ca to Cr ratio was found to be 0.8 mmol/nmol
as the upper limit, and if the in any case it was higher than that, the contributing
factors were measure and it was subjected to variables such as dietary implements and
its exposure to sunlight. If the urinary Ca to Cr ratio exceed more than 1 and the
serum calcium levels surpassed 2.75 mmol/L, then the supplementation of Vitamin D
were stopped. The prominence of hypervitaminosis D was not observed in men and
non pregnant women and recently among pregnant women between 1000 to 10,000
IU/d.In our observation it was monitored that vitamin D deficiency using 25O(H)D
serum was found to be less 10 ng/mL (<25 nmol/L) and it falls under the osteomalacic
range.
Due to the reason of ethical issues, the participants with serum 25(OH)D
concentrations less than 10 ng/mL for 3 to 4 months of Vit D supplementation, were
considered and were referred to the Research Ethical (REC) . The Research Ethical
Committee (REC) comprises of biostatistician, clinical pathologist endocrinologist
and intern with obstetrics and gynecology who did supervise and reviewed the
continuation of supplementation of the vitamin D decrease and medication
8

9BIOLOGY ASSIGNMENT
compliance were also measured.
On the basis of data, the participant Indian women who were documented to
take 400 IU/d vitamin D tablets in the last trimester of the gestation period had less
than 5% of 25(OH)D serum and after three months of intake of vitamin D tablets less
than 10 ng/mL was documented.
Sample size calculation
In the key level the maternal serum was found to be 25(OH)D during the
delivery. Based on the studies, it was understood that there was difference in the doses
from of vitamin D tablets those doses are 400IU/d, 2000 IU /d and 4000 IU/d of 10ng/
ml which is 25nmol/L. There were total 192 participants, and there were 64
participants in each group.
Statistical analysis
Initially the amount of serum 25(OH)D were varying in the volunteering
mothers. A statistical analysis was done to examine and study each variable among
the distribution of the subject. Initial analysis consisted of comparing the three groups
at a time and then the study was made in to mixed model by the analysis procedure of
SAS PROZ MIXED. The serum levels of 25(OH)D were determined. There were
routine measurements of the serum levels of the groups. Later on the analysis was
done by comparing the different means between each group in every interval of time.
Then the analysis was done by intention-to-treat randomized procedure in the groups.
In the secondary outcome the segregation was done by understanding the mothers
who gained serum level 25(OH)D 32ng/ml or more than or equal to 80nmol/ L.
9

10BIOLOGY ASSIGNMENT
5. SCOPE OF THE STUDY
Randomized controlled trials are available to support the need for, and benefits
of, vitamin D supplementation in pregnancy. The randomized control trials were
conducted to study the better impact of vitamin D intake in pregnant women. The
previous research which were conducted were only for three to four months, which
were comparatively shorter in duration, however in the present study we have
investigated the effect of vitamin D supplementation on the daily basis to the pregnant
mothers for six months.
In an investigation by Hollis et al. (2011) showed that there was a specific
decrease in complications during pregnancy which included the primary Cesarean
section and hypertensive disorder and then obesity disorder in women who were
pregnant. It has not however, found any correlation between maternal vitamin D and
birth weight. However, the relation between the weight during the birth and maternal
level of Vitamin D was not confirmed. At the same time there was no significant
observable adverse reactions were noted due to intake of Vitamin D.
In a study by Holles et al. (2011) it was found that due to the duration of the
investigation that is from the 12th week of the pregnancy period the does were 400
UI/d, 2000IU/d and 4000IU/d. An ethical decision was taken into consideration the
control group of 400IU/d however, for the larger group the approval of FDA was
required to for nearly 30 years. Similar to the end results by Dawodu et al. (1997) it
was found that the intake of Vitamin D according to doses of 2000 IU/d and 4000
IU/d during the 12th and 16th weeks of the pregnancy period would reduce the
deficiency of the vitamin D in Indian women. By this results it can be confirmed that
the intake of vitamin D tablets can reduce the vitamin D deficiency.
10

11BIOLOGY ASSIGNMENT
The required guidelines which are available with respect to the Vitamin D
intake, are not enough to understand or interpret the deficiency of Vitamin D in
pregnant mothers in this particular region against the standard dose of Vitamin D
intake. Although, the intake of Vitamin D during the non-pregnancy stage is less, but
during the gestation period the level of Vitamin D needs more supplementation of this
specific nutrient not only for the pregnant mothers but also for the prenatal
development of the child. However, we keep on recommending lower dosages to
pregnant ladies than to their non-pregnant friends, maybe in light of an unwarranted
dread of reactions. But the standard dose recommended for the pregnant women is
still lesser as compared to the non-pregnant females, mainly due to the unwanted side
effects of Vitamin D intake.
The deficiency of Vitamin D intake amongst the pregnant mothers should be
clinically treated in the same way the treatment is given for the women who are not
pregnant. However, in this research the dose of 4000 UI / day has proven to be
effective when it comes to the deficiency of Vitamin D. The utilization of lower
portions of nutrient D, as contained in most pre-birth calcium arrangements (100-800
IU) can't be overlooked in symptomatic patients, or in those with recorded low
dimensions. The mothers with lower doses of vitamin D from, showed symptoms and
have high probability of low levels of decrease in prenatal calcium levels, from100
to800 IU, and these symptoms cannot be over looked in this scenario.
However, it can be understood that the pregnant ladies who had Vitamin
tablets for the dose of 1000-2000 IU per day, particularly in the third and the second
trimester of their gestation period showed no abnormal conditions of Vitamin D
intoxication and no further risk of inborn teratogenicity. Although this data was
effective for the first and the second trimester, this data does not assure any
11